Conception, évaluation et impact d'une aide à la décision informatisée destinée aux pharmaciens cliniciens

Ce travail de doctorat s'intéresse à l'élaboration d'un système d'aide à la décision clinique destiné aux pharmaciens cliniciens. Ses objectifs sont l'amélioration de la couverture des pharmaciens cliniciens dans les hôpitaux universitaires ; la réduction du phénomène de fatigue aux alertes (particulièrement lorsque des alertes sont adressées aux médecins). En plus de décrire l'élaboration d'un tel système et son application en médecine interne-pour le ciblage d'une sélection de situations à risque d'iatrogénie-pour la prévention d'évènements indésirables médicamenteux durant la première vague de COVID-19, cette thèse propose des modèles de conception de bases de connaissances susceptibles d'alimenter un tel outil. Nous avons observé qu'un tel système était pertinent pour détecter automatiquement des problèmes reliés à la pharmacothérapie avec des performances satisfaisantes. Une collaboration étroite avec des médecins spécialistes, permet d'identifier ces situations de manière objective, en tenant compte de critères de pertinence et criticité

Development and retrospective evaluation of a clinical decision support system for the efficient detection of drug-related problems by clinical pharmacists

Background: Clinical decision support systems (CDSS) can help identify drug-related problems (DRPs). However, the alert specificity remains variable. Defining more relevant alerts for detecting DRPs would improve CDSS. Aim: Develop electronic queries that assist pharmacists in conducting medication reviews and an assessment of the performance of this model to detect DRPs. Method: Electronic queries were set up in CDSS using "triggers" from electronic health records: drug prescriptions, laboratory values, medical problems, vital signs, demographics. They were based on a previous study where 315 patients admitted in internal medicine benefited from a multidisciplinary medication review (gold-standard) to highlight potential DRPs. Electronic queries were retrospectively tested to assess performance in detecting DRPs revealed with gold-standard. For each electronic query, sensitivity, specificity, positive and negative predictive value were computed. Results: Of 909 DRPs, 700 (77.8%) were used to create 366 electronic queries. Electronic queries correctly detected 77.1% of DRPs, median sensitivity and specificity reached 100.0% (IQRs, 100.0%-100.0%) and 99.7% (IQRs, 97.0%-100.0%); median positive predictive value and negative predictive value reached 50.0% (IQRs, 12.5%-100.0%) and 100.0% (IQRs, 100.0%-100.0%). Performances varied according to "triggers" (p &lt; 0.001, best performance in terms of predictive positive value when exclusively involving drug prescriptions). Conclusion: Electronic queries based on electronic heath records had high sensitivity and negative predictive value and acceptable specificity and positive predictive value and may contribute to facilitate medication review. Implementing some of these electronic queries (the most effective and clinically relevant) in current practice will allow a better assessment of their impact on the efficiency of the clinical pharmacist.</p

Electronic monitoring of potential adverse drug events related to lopinavir/ritonavir and hydroxychloroquine during the first wave of COVID-19

During Switzerland's first wave of COVID-19, clinical pharmacy activities during medical rounds in Geneva University Hospitals were replaced by targeted remote interventions. We describe using the electronic PharmaCheck system to screen high-risk situations of adverse drug events (ADEs), particularly targeting prescriptions of lopinavir/ritonavir (LPVr) and hydroxychloroquine (HCQ) in the presence of contraindications or prescriptions outside institutional guidelines. Of 416 patients receiving LPVr and/or HCQ, 182 alerts were triggered for 164 (39.4%) patients. The main associated risk factors of ADEs were drug-drug interactions, QTc interval prolongation, electrolyte disorder and inadequate LPVr dosage. Therapeutic optimisation recommended by a pharmacist or proposals for additional monitoring were accepted in 80% (n=36) of cases. Combined with pharmacist contextualisation to the clinical context, PharmaCheck made it possible to successfully adapt clinical pharmacist activities by switching from a global to a targeted analysis mode in an emergency context

Development and assessment of PharmaCheck: an electronic screening tool for the prevention of twenty major adverse drug events

Background: Adverse drug events (ADEs) can be prevented by deploying clinical decision support systems (CDSS) that directly assist physicians, via computerized order entry systems, and clinical pharmacists performing medication reviews as part of medical rounds. However, physicians using CDSS are known to be exposed to the alert-fatigue phenomenon. Our study aimed to assess the performance of PharmaCheck-a CDSS to help clinical pharmacists detect high-risk situations with the potential to lead to ADEs-and its impact on clinical pharmacists’ activities. Methods: Twenty clinical rules, divided into four risk classes, were set for the daily screening of high-risk situations in the electronic health records of patients admitted to our General Internal Medicine Department. Alerts to clinical pharmacists encouraged them to telephone prescribers and suggest any necessary treatment adjustments. PharmaCheck’s performance was assessed using the intervention’s positive predictive value (PPV), which characterizes the proportion of interventions for each alert triggered. PharmaCheck’s impact was assessed by considering clinical pharmacists as a filter for ruling out futile alerts and by comparing the final clinical PPV with a pharmacist (the proportion of interventions that led to a change in the medical regimen) to the final clinical PPV without a pharmacist. Results: Over 132 days, 447 alerts were triggered for 383 patients, leading to 90 interventions (overall intervention PPV = 20.1%). By risk class, intervention PPVs made up 26.9% (n = 65/242) of abnormal laboratory value alerts, 3.1% (4/127) of alerts for contraindicated medications or medications to be used with caution, 28.2% (20/71) of drug-drug interaction alerts, and 14.3% (1/7) of inadequate mode of administration alerts. Clinical PPVs reached 71.0% (64/90) when pharmacists filtered alerts and 14% (64/242) if they were not doing it. Conclusion: PharmaCheck enabled clinical pharmacists to improve their traditional processes and broaden their coverage by focusing on 20 high-risk situations. Alert management by pharmacists seemed to be a more effective way of preventing risky situations and alert-fatigue than a model addressing alerts to physicians exclusively. Some fine-tuning could enhance PharmaCheck's performance by considering the information quality of triggers, the variability of clinical settings, and the fact that some prescription processes are already highly secured.</p

Impact d’une réconciliation médicamenteuse par un pharmacien lors de l’admission dans un service de médecine interne

Le risque d’erreurs médicamenteuses est accru à l’admission d’un service de soins. L’interface ville/hôpital expose à un risque de discontinuité dans la prise en charge médicamenteuse en induisant des divergences non intentionnelles de prescription (DNI) entre traitements habituels et hospitaliers. L’objectif de cette étude était d’évaluer l’incidence des DNI et de mesurer l’impact d’une réconciliation médicamenteuse à l’admission sur la justesse de la prescription hospitalière en médecine interne